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. COUNTY' Dt dcbess
CITYITOWN Wappinger
~~J~k~T 1368
~Q~I~J~R 88
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
~ A. D'Engm~NAME
FIRST
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Mi~, E. Rom~SURNAME
-.J
1. A. FULL NAME
11. A. FULL NAME
FIRST
0-
N
B BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE no Entrernant
(OPTIONAL. SEE REVERSEr::
D. SOCIAL SECURITY NUMBER Q52..~
12. RESIDENCE A. N'lrATE) B. ~
C. CHECK ONE 0 CITY ~OWN 0 VILLAGE
AND Wa .
SPECIFY ppnger
D. STREET ADDRESS 52 Osborne HII Road. U 35'IP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES fJ' NO
MQi / ~ "1'_
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 114-66-7013
2. RESIDENCE A N";t B. ~I
(S ATE)
C. CHECK ONE 0 CITY Iil'TOWN 0 VILLAGE
AND ~ Igbkeepsi
SPECIFY ft. e
D. STREET ADDRESS 152 Smith ~
3. A. AGE 36
ZIP 12603
YES ~ NO
/~f1i7
13.8. DATE OF BIRTH
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
MO~ /~
4. EMPLOYMENT
13. A. AGE 13
14. EMPLOYMENT
A. USUAL OCCUPATION Depl Manager
8. TYPE OF INDUSTRY OR BUSINESS A & P SUpem1eltets
15. PLACE OF BIRTH p-.....~.. I\IMuYodc
(C~I'I"~~
16. FATHER
3B. DATE OF BIRTH
A. USUAL OCCUPATION C()flstrucliOf'l
B. TYPE OF INDUSTRY OR BUSINESS 1Vn<< PrIde Homes
5. PLACE OF BIRTH ~~MM"I~
6. FATHER
A. NAME ""'" Ir [1Enlremont
B. COUNTRY OF BIRTH USA
7. MOTHER
A MAIDEN NAME jamie Smith
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
A. NAME Frank Ramanelli
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Inez V8IdeI'
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
DEATH
1 0 0
8. HOW DID LAST MARRIAGE END? (3) cY'olVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 01 / ?? / ?NY>
MONTH D1!'f*' ~
D. ARE ANY FORMER SPOUSE(S) ALIVE? i:Y\'ES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
100
8. HOW DID LAST MARRIAGE END? (3) MIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 08 / 'IA / 'IQQ4
MONTH oJ!!' 1'~
D. ARE ANY FORMER SPOUSE(S) ALIVE? OlII'ES 0 NO
20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
0811811994 PoughkMpll.. Nw-: York 0.; 0
o 0
o 0
o 0
no egal impediment exists
1ST
2ND
3RD
4TH
I, being duly sworn, depose and say, that t
as to my right to enter into the marriage s
21. SIGNATURE OF GROOM ~
UJ
en
z
UJ
()
::;
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized
Relations Law ~11 to perform marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used only for the purpose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
DATE 07/CIl12CXJ3
by New York Domestic
.-"-..
{ SEAL }
'-v-'
NAME (PRINT)
TIME
MONTH
YEAR
MONTH
YEAR
07
08
09
05 2003
STR
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK 8. COUNTY ~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
jil' CITY OF 0 TOWN OF 0 VILLAGE OF
SPECIFY ~\l':Jh~,~
\r:..a.. ~\~ ~ch
29. OFFICIANT
NAME (PRINT)
NAME (PRINT)
SIGNATURE ~